Recurrent giant cell tumor of the flexor digitorum superficialis tendon sheath
Patient presented with a painless firm swelling over the antero-medial aspect of the proximal phalanx of her middle finger. There was a past history of resected similar lesion at almost the same site.
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An oval shaped soft tissue lesion seen related to the radio-palmer aspect of the distal portion of the proximal phalanx of the left middle finger showing overlying skin bulge and underlying bone scalloping.
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A lobulated well-defined lesion is seen intimately related to the distal portion of the radial slip of the flexor digitorum superficialis tendon of the left middle finger. The lesion showed intermediate-to-low signal on both T1W and T1W images, high signal on T1W-FS and STIR images and almost no enhancement on post-contrast T1W images.
The most common soft tissue lesion of the hand and wrist is ganglion cyst followed by giant cell tumor of the tendon sheath (GCTTS). The former is usually seen along the dorsum of the wrist and the latter is usually seen within the fingers 2. GCTTSs are rare benign lesions of giant cells usually seen arising from tendons and hence the characteristic location related to joints. They are closely related to pigmented villo-nodular synovitis and termed by some as extra-articular pigmented villo-nodular synovitis 4,5. They may contain hemosiderin and may enlarge to destroy adjacent bone 3.
The affected patients are usually in their 20-40 years of age; with no definite sex predilection 3.
The most common presentation is a firm, non-tender mass related to a hand or wrist joint 1.
The most helpful diagnostic procedure is MRI 4. The best diagnostic combination is: soft-tissue tumor near a joint or along a tendon sheath showing intermediate signal intensity on T1 and T2W images with hemosiderin deposits 3,5. MRI appearance may include low to intermediate signal with low signal septa on T1W images, low to intermediate with low signal hemosiderin foci on T2W images and may be inhomogeneous on both. Additional imaging findings may include convex bowing toward the skin from the tendon sheath, flexor or extensor tendon relation and adjacent osseous compression erosion 2,5.
The treatment of choice is complete excision of the lesion. Unfortunately, there is a high rate of lesion recurrence, which is reported to be 10-20 % (9-44%) 4,6. Incomplete excision and leaving behind satellite nodules is considered as the most important factor determining recurrence 6. Therefore, a balanced compromise between total resection of tumor and maintenance of tendon function must be achieved 1. There has been a recent suggestion to use fine needle aspiration cytology (FNAC) as a primary diagnostic tool. Preoperative diagnosis of GCTTS was attained using FNAC and may help in preoperative planning to prevent recurrence 6.
The case was pathologically proved.
- 1- Adams EL, Yoder EM, Kasdan ML. Giant cell tumor of the tendon sheath: experience with 65 cases. Eplasty. 2012;12: e50. Free text at pubmed - Pubmed citation
- 2- Burgener FA, Meyers SP, Tan RK. Differential diagnosis in magnetic resonance imaging. Thieme. ISBN:313108121X. Read it at Google Books - Find it at Amazon
- 3- Reiser MF, Baur-Melnyk A, Glaser C. Direct diagnosis in radiology: Musculoskeletal Imaging. Thieme. ISBN:3131451610. Read it at Google Books - Find it at Amazon
- 4- Rukavina I, Ćaleta D. Giant-cell tumour of the tendon sheath: A review. OA Orthopaedics 2014 Jun
- 5- Stoller D, Tirman P, Bredella M et-al. Diagnostic Imaging: Orthopaedics. AMIRSYS. (2004) ISBN:0721629202. Read it at Google Books - Find it at Amazon
- 6- Suresh SS, Zaki H. Giant cell tumor of tendon sheath: case series and review of literature. J Hand Microsurg. 2010;2 (2): 67-71. doi:10.1007/s12593-010-0020-9 - Free text at pubmed - Pubmed citation